Republic of South

Situation Report #39 on Cholera in As at 23:59 Hours, 30 July 2015

Situation Update As of 30 July 2015, a total of 1,383 cholera cases including 42 deaths (CFR 3.04%) have been reported in and Bor Counties in Central and Jonglei States respectively. In Juba County, 1,268 cases including 41 deaths (CFR 3.23%) have been reported from seven Payams (Table 1). In Bor, 115 cases including one death (CFR 0.87%) have been reported from Malou in Makuach Payam and other areas within the County.

The initial cases in Juba were traced back to 18 May 2015 in UN House PoC where the first cholera case was confirmed on 1 June 2015. The most affected Payams in Juba County are Kator, , Northern Bari, and Munuki that have registered attack rates (cases per 10,000) of 200, 191, 139, and 25 respectively (Annex 1).

In Bor, the initial cases were reported from Malou in Makuach Payam. Makuach Payam is the most affected in Bor and has registered an attack rate (cases per 10,000) of 30 (Annex 1 and 2).

Table 1. Summary of cholera cases reported in Juba and Bor Counties, 18 May – 30 July 2015 Reporting Sites New New New Total cases LAMA* Total Total Total Total cases Total cases admisions discharges deaths currently facility community deaths discharged admitted deaths deaths

CES – Juba County 8 12 0 34 205 25 16 41 988 1268 IMC UN House PoC clinic 0 0 0 0 0 0 1 1 71 72 Juba Teaching Hospital 4 8 0 30 201 21 7 28 698 957 MedAir Gumbo CTU 0 0 0 1 0 1 0 1 74 76 MedAir Gudele ORP 0 0 0 0 0 0 0 0 8 8 HLSS Nyakuron ORP 1 1 0 0 0 0 0 0 22 22 HLSS Kator ORP 0 0 0 0 0 0 0 0 6 6 HLSS Gurei ORP 0 0 0 0 0 0 0 0 34 34 HLSS Munuki ORP 0 0 0 0 0 0 0 0 3 3 HLSS Al Sabah ORP 1 1 0 0 0 1 0 1 9 10 HLSS Lologo ORP 0 0 0 0 0 0 0 0 8 8 MSF Munuki CTC 2 2 0 3 4 0 0 0 37 44 Other sites in Juba 0 0 0 0 0 2 8 10 18 28 – Bor 0 1 0 0 3 1 0 1 111 115 Bor State Hospital 0 1 0 0 3 1 0 1 111 115 Total 8 13 0 34 208 26 16 42 1099 §1383 *LAMA: LEAVE AGAINST MEDICAL ADVICE; CES- State; § Following data cleaning, 56 duplicate records were deleted from the database. A total of eight new cholera cases were reported in Juba on 30 July 2015 (Table 1 and Figure 1). o Eight new cases were reported from Juba County, with the majority originating from Mia Sava in Munuki Payam. o There was no new case reported from Bor on 30 July 2015.

Figure 1: New cholera cases by residence on 30 July 2015 3

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1 2 1 1 1 1 1 1 0 Mia Sava Nyakuron PRRS Dar Salam Jebel Lemunigaba Kodoro Number casesofNumber West Checkpoint Munuki Northern Bari Rejaf Juba

1 During week 31 of 2015 (week of 30 July 2015), most of the cholera cases in Juba originated from Kor William and Lologo in Kator; Jebel Dinka, Lokuilili, and Hai Baraka in Northern Bari; Hai Jebel, Nyakuron west, and Mia sava in Munuki; and Gumbo in Rejaf (Figure 1.1). During week 31 of 2015, the most affected Payams in Juba County were Kator, Northern Bari, Rejaf and Munuki that registered attack rates (cases per 10,000) of 10, 8.2, 5.6, and 1.2 respectively (Annex 1).

Figure 1.1: New cholera cases by residence during week 31 of 2015

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Cumulatively, 1,383 cholera cases including 42 deaths (26 facility and 16 community) have been reported in Juba and Bor Counties since the initial case was reported on 26 May 2015 in Juba (Tables 1 and 2). Of the 42 deaths, nine (21%) occurred in children under five years while 27 (64%) occurred in males. In Juba County, Juba Payam has registered the highest CFR followed by Northern Bari, Rejaf, Munuki and Kator (Annex1).

Table 2: New cholera cases by facility and week in Juba and Bor Counties, 18 May – 30 July 2015 New cases by epidemiological week of 2015 Reporting Facility 21 22 23 24 25 26 27 28 29 30 31 Grand Total CES – Juba County 4 2 7 56 130 229 235 161 237 150 57 1268 JTH 0 2 2 32 119 208 207 116 146 93 32 957 Juba 3 IMC clinic 4 0 4 9 6 13 10 10 11 5 72 HLSS Nyakuron ORP 0 0 0 0 0 0 2 3 11 2 4 22 HLSS Kator ORP 0 0 0 0 0 0 0 3 1 2 6 MedAir Gudele ORP 0 0 0 0 0 0 0 4 3 1 8 MedAir Gumbo CTU 0 0 0 0 0 5 15 20 25 10 1 76 HLSS Gurei ORP 0 0 0 0 0 0 0 1 11 10 12 34 HLSS Munuki ORP 0 0 0 0 0 0 0 1 0 2 3 HLSS Al Shabah ORP 0 0 0 0 0 0 0 0 4 3 3 10 HLSS Lologo ORP 0 0 0 0 0 0 0 0 2 4 2 8 MSF Munuki CTC 0 0 0 0 0 0 0 0 23 18 3 44 Other sites in Juba 0 0 1 15 5 3 1 3 0 0 28 Jonglei State – 0 0 0 0 0 5 46 33 21 8 2 115 Bor State Hospital 0 0 0 0 0 5 46 33 21 8 2 115 Grand Total 4 2 7 56 130 234 281 194 258 158 59 1383

As seen from Figure 2, the initial and isolated cases were reported from UN House PoC in Juba starting on 26 May 2015. However, following epidemiological investigations on 27 May 2015, cases could be traced back to 18 May 2015. Cholera was eventually confirmed on 1 June 2015 in Juba after Vibrio cholerae inaba was isolated from the one of five samples tested in the National Public Health Laboratory.

Since 6 June 2015, sustained and consistently increasing community transmission was established in Juba with increasingly more suspect cases reported outside UN House PoC. There are four transmission peaks with the initial peak of 15 cases occurring on 13 June 2015 while the subsequent and higher peaks occurred on 20 June, and 26 June before reaching the second highest peak on 28 June. Since then, successively shorter transmission peaks were registered. This trend was largely driven by sustained community transmission in Juba, Northern Bari, Rejaf, Munuki, and Kator Payams (Annex 2). On 19 July 2015, a total of

2 61 new cases in Juba County were linked to a funeral in Atlabara B, thus resulting into the highest peak during the outbreak. Since then, a steady decline in cases has been registered in Juba.

In Bor, the initial case occurred on 26 June 2015 with increasing cases from week 26 to week 27 when the highest transmission peak was registered. In the subsequent weeks, successively shorter transmission peaks were registered, a trend that is consistent with declining community transmission.

Figure 2: Epidemic curve for cholera cases in Juba and Bor, 18 May – 30 July 2015

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70 17.9 18 16 60 14.3 14 50 12 40 10 30 8 6.2 6 20

Number Number of cases 3.8 4 10 1.9 2 1.4 1.5 1.6 FatalityCase Rate [%]

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5/24/15 6/14/15 5/15/15 5/18/15 5/21/15 5/27/15 5/30/15 6/11/15 6/17/15 6/20/15 6/23/15 6/26/15 6/29/15 7/11/15 7/14/15 7/17/15 7/20/15 7/23/15 7/26/15 7/29/15 20 21 22 23 24 25 26 27 28 29 30 31

JS CES CFR

JS: Jonglei State; CES: Central Equatoria State; CFR: Case Fatality Rate

The probable risk factors fueling transmission include: residing in a crowded IDP camp with poor sanitation and hygiene; using untreated water from the Water tankers; lack of household chlorination of drinking water; eating food from unregulated roadside food vendors or makeshift markets; open defecation/poor latrine use; and attending/eating food at a funeral.

Figure 3: Spot map for cholera cases by residence in Juba, 18 May – 30 July 2015

3 As of 30 July 2015, the sites reporting the majority of cases in Juba include Gumbo, New site, Juba 3 PoC, Gudele 2, Atlabara B, and Munuki with satellite cases distributed in seven Payams in Juba County (Figure 3). In Bor County, the majority of the cases originated from Malou 41 (36%) and Langbar 12 (10.4%) in Makuach Payam.

The most affected age groups in Juba and Bor counties are children under five and 5-9 years old. Additionally, a significant number of cases have occurred among 25-29 year olds in Juba County (Tables 3.1 and 3.2).

Table 3.1: Cholera case distribution by age in Juba County, 18 May – 30 July 2015 Cholera case distribution by age in Juba County, week 21-31, 2015

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150 113 102 Male 100 85 75 80 Female 42 45 54 50 76 84 45 Number Number of cases 64 72 45 44 14 15 38 37 24 5 11 10 0 19 15 11 7 115 7

Table 3.2: Cholera case distribution by age in Bor County, 18 May – 30 July 2015 Cholera case distribution by age in Bor County, week 26-31, 2015 80

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60 50 33 40 Male 30 20 Female

Number Number of cases 34 10 6 3 1 8 8 2 1 0 5 1 1 2 3 1 3 1 1 under 5-9 10-14 15-19 20-24 30-34 35-39 40-44 45-49 50-54 55-59 65-69 five years years years years years years years years years years years years

Out of the 1,262 cholera cases with known gender in Juba, 549 (44%) were female, while 713 (56%) were male while in Bor, 67 (58%) of the cases were females, while 48 (42%) were males (Table 4).

Table 4: Case distribution by gender and age in Juba and Bor Counties, 18 May – 30 July 2015 Case distribution by gender N (%) CES - Juba 1262 Female 549 (44) Male 713 (56) Jonglei state – Bor County 115 Female 67 (58) Male 48 (42) Grand Total 1377

Laboratory updates

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Table 5: Cholera laboratory test results for Juba and Bor, 18 May – 30 July 2015 Number of Number of cholera Number of stool Number of cholera Health Facility RDT tests RDT positives cultures Culture positives CES – Juba 219 197 89 35 1 Juba Teaching Hospital 126 113 54 17 2 Juba 3 PoC clinic 67 61 22 11 3 MSF Munuki CTC 14 14 1 0 4 Other sites in Juba 12 9 10 5 5 MedAir Gumbo CTU 0 0 2 2 Jonglei state – Bor 57 49 17 8 1 Bor State Hospital 57 49 17 8 Total 276 246 106 43

As seen from Table 5, 248 (89%) of the samples have been RDT positive while 43 (41%) have been confirmed by culture after the National Public Health Laboratory isolated Vibrio cholerae inaba. Most of the culture confirmed cases have been reported from Juba 3 PoC, New site, Munuki, and Nyakuron West in Juba while in Bor, Malou has registered the highest number of confirmed cases (Figure 4).

Seven stool samples were shipped to the Central Public Health Laboratory in Uganda for testing. Vibrio cholerae Inaba serogroup, 01 serotype was isolated from one of the samples while six samples tested negative for cholera but were positive for nonpathogenic Escherichia coli. Three isolates were confirmed as positive and three negative samples tested negative on repeat testing in Uganda thus confirming earlier test results by the National Public Health Laboratory. The four isolates were sensitive to tetracycline and ciprofloxacin; intermediate for Ampicillin and chloramphenicol and resistant to Sulphamethoxazole.

Figure 4: Number of culture positives by residence in Juba and Bor, 18 May – 30 July 2015

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MangatainIDP Nyakuron West Juba Bor

Table 6: Cholera Alerts – 23 to 30 July 2015 Date of Details of the alert Area Action notification 28-Jul-15 A community death involving a 5-year-old Lokuilili, - State and county surveillance officers notified to boy occurred in Lokuilili. He was buried Juba verify the death. on 27 July 2015 and his mother was Payam - Mother to the deceased case admitted to MSF admitted in the MSF Munuki CTC with Munuki CTC for treatment. cholera symptoms on the same day. 26-Jun-15 Nineteen suspect cholera cases were , - A total of 65 acute watery diarrhoea cases have initially reported in Kajo Keji Civil hospital. CES been line listed with two cases on admission at The cases have now risen to a the hospital cumulative total of 65. - 21 samples submitted for microbiological culturing - 19 samples tested negative for cholera following microbiological culturing at the National Public Health Laboratory while two are pending - An assessment by MedAir revealed there were no active suspect cases. Refresher training on cholera undertaken and cholera case management stockpiles were replenished -

5 Since 25 June 2015, at least 10 alerts of suspect cholera cases have been reported outside Juba. The national and respective state cholera taskforce committees have initiated the recommended follow up actions as described in Table 6.

Planned and On-going Activities 1. The next national cholera taskforce meeting is scheduled for Monday 3 August 2015 at 10:00 am in the Ministry of Health Ministerial Boardroom. 2. The next cholera coordination meeting in UN House PoC is scheduled for 6 August 2015 at 11:30 am in the RRP Boardroom.

Many thanks to the staff at CTCs, MoH at national level and state levels, especially the Department of IDSR, who have helped to gather the information presented here. Situation Reports are posted on the WHO website: http://www.who.int/hac/crises/ssd/en/ as well as on the Humanitarian Info webpage: http://southsudan.humanitarianresponse.info/clusters/health.

The MoH/WHO surveillance team welcomes feedback and data provided by individual agencies. Given the fast evolving nature of this epidemic, errors and omissions are inevitable: we will be grateful for any information that helps to rectify these. Send any comments and feedback to: E-mail: [email protected], The Toll free numbers for alerts are: Zain: 0912000098.

Contacts For more information please contact: Dr. John Rumunu Dr. Thomas Akim Ujjiga Director General - Preventive Health Services Director - IDSR MoH, Republic of South Sudan MoH, Republic of South Sudan Tel: +211955668178 Tel: +211955150406

Annex: Cholera Data tables and Charts – 18 May 2015 to 30 July 2015

Annex 1: Cholera attack rates and case fatality rates by Payam, 18 May to 30 July 2015 New Attack rate cases in [cases per Cumulative week 31, Case 10,000] for Attack rate 2015 Total Total Populati Fatality week 31 of [cases per Location Cases Deaths on Rate [%] 2015 10,000] CES 59 1268 41 279871 3.2 2.1 45.3 0 7 7115 - 9.8 Juba 5 137 11 91254 8 0.5 15 Kator 12 228 5 11395 2.2 10.5 200 Lokiliri 0 3 5995 - 5.0 Munuki 15 328 8 129133 2.4 1.2 25.4 Northern Bari 17 288 8 20753 2.8 8.2 138.8 Rejaf 8 271 7 14226 2.6 5.6 190.5 (Blank) 0 5 2 40.0 JS 2 115 1 181708 0.9 0.1 6. 3 0 4 51042 - 0.8 Bor 0 5 61224 - 0.8 0 1 40021 - 0.2 Makuach 1 89 1 29421 1.1 0.3 30.3 Grand Total 61 1383 42 461579 3.0 1.3 30

Annex 2: Cholera epidemic curves by Payam – 18 May to 30 July 2015

6 Cholera Epidemic Curve Juba Payam 2015

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Cholera Epidemic curve Northern Bari Payam 2015

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Cholera Epidemic Curve Rejaf Payam 2015

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7 Cholera Epidemic Curve Munuki Payam 2015

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Cholera Epidemic Curve Kator Payam 2015

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Cholera Epidemic Curve Gondokoro Payam 2015

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8 Cholera Epidemic Curve Lokiliri Payam 2015

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Cholera Epidemic Curve Makuach Payam, Bor 2015

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